Provider Demographics
NPI:1558094383
Name:WILSON, VERONICA DMITRIYA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:DMITRIYA
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:DMITRIYA
Other - Last Name:GORENSHTEYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1715 FRIENDSHIP CIR STE 300
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-6920
Mailing Address - Country:US
Mailing Address - Phone:770-240-0163
Mailing Address - Fax:770-240-0163
Practice Address - Street 1:1715 FRIENDSHIP CIR STE 300
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-6920
Practice Address - Country:US
Practice Address - Phone:770-240-0163
Practice Address - Fax:770-240-0163
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003297349AMedicaid